Transhiatal Esophagectomy after Previous Left Pneumonectomy: Challenge of Surgical Approach, a Case Report

The occurrence of esophageal cancer after previous pneumonectomy for primary lung cancer is rare. This is the second case report of transhiatal esophagectomy after previous pneumonectomy due to lung cancer. In this case, selection of surgical approach for esophagectomy, was technically challenging and anatomic deformity in post pneumonectomy space had potential risk of physiologic disturbance, especially after thoracotomy option in solitary lung with limited capacity. Case presentation: We herein report a 58 year old man with history of left pneumonectomy and lymph node dissection due to mucoepidermoid carcinoma 19 years ago and recently admitted for esophageal carcinoma. He successfully was managed via transhiatal approach. Conclusion: Transhiatal esophagectomy in pneuminectomized patient is safe and recommended as first option.


INTRODUCTION
Esophagectomy in setting of prior pneumonectomy is a challenging issue, and there is little experience in this area with only a few cases reported to date (1)(2)(3)(4)(5). This is the second report of a transhiatal esophagectomy after prior pneumonectomy due to lung cancer.

CASE SUMMARY
A 58-year-old man referred to our teaching hospital with progressive dysphagia from 2 months ago. He could only take down soft drink. The patient had undergone left pneumonectomy and lymph node dissection for mucoepidermoid carcinoma (pT3N1M0) 19 years ago. He was worker with no history of smoking but recently became diabetic and was controlled with oral anti hyperglycemic drugs. He underwent barium swallow which showed irregular mass and deformity in lower third, then Esophagoscopy showed tumor in 32 cm from the incisors. Biopsies were taken and moderately differentiated squamous cell carcinoma was the confirmed diagnosis.
Preoperative spiral chest and abdominal CT scan was done to evaluate the thoracic anatomy, lymphadenopathy and surgical plan and approaches. Whole body scan was done to assess the presence of any metastatic disease. CT of the chest demonstrated marked anatomic deviation, hyper expansion of the right lung, mediastinum shift to the left hemithorax, and reduced left intrathoracic space with heterogeneous opacification (Figure 1, 2). No metastasis or lymphadenopathy was found in brain magnetic resonance imaging (MRI), whole body scan, chest and abdominal CT scan.  In preoperative cardiovascular workup, ejection fraction was 60%, Pulmonary function test also showed a forced expiratory volume (FEV1) of 1.23 L (56% predicted), forced vital capacity (FVC) of 1.50 L (50% predicted). ABG in room atmosphere was normal and he could walk two floors up without dyspnea.
Our assessment was based on the preoperative cardiovascular assessment, pulmonary function tests, data and imaging indicating the operability of tumor. The preferred method was an approach without thoracotomy due to limited lung capacity and possible physiologic disturbance. Thus, the initial operative plan was transhiatal approach. However, possible intra operative unpredictive findings may necessitate change the operative approach.
Although transthoracic tree hole approach was an alternative favorite, operating in solitary lung and manipulation in this area may be hazardous. We had many difficulties in entering the left chest, due to extensive fibrotic scar tissue, obliteration of the post pneumonectomy space and significant anatomic distortion, so, the final decision was made to precede on Transhiatal esophageal resection without any neo adjuvant modality. Because of dense adhesions we were hardly able to release the periesophageal tissue; however, our final specimen was stripped adventitial tissue.
Then gastric conduit was brought up to the neck in a sterile manner and functional end-to-end anastomosis with separated absorbable monofilament suture was performed.  In this patient neoadjuvant radiation therapy is not recommended because of concern of worsening of extensive fibrosis that is already present from previous pneumonectomy, although data this area is not adequate.
One the most important reasons of selecting transhiatal approach was our greater experience in transhiatal esophagectomy than any others option and many of surgeons may be unfamiliar with post pneumonectomy area with many pitfalls. Moreover, transhiatal esophagectomy may protect the residual pulmonary reserve, managing the potential anastomotic leak better.
Although our experience in this case revealed transhiatal esophagectomy in pneuminectomized patient is safe, and may be recommended as first option, but this surgical approach should be optimized on individual basis.
The procedure presented here is applicable for tumors of the lower third, while tumors located in the upper and middle third may be impossible for resection with this approach; however, extracorporeal membrane oxygenation (ECMO) has been introduced to enable surgery in these patients (4).